Do I need prior authorization before going to the emergency room?

Health insuranceDeniedChecked Nov 5, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: eCFR · 45 CFR 149.110 · § 149.110(a), (b)(1), (b)(3)(ii), (b)(4) View original ↗

In short

Health plans that cover ER care cannot require prior approval for emergency services.
This is true even if the ER is out of network.
If you were denied for "no prior auth," appeal and quote the rule.

What this means

A federal rule covers this. If a job-based health plan or a health insurer covers ER care, it must cover emergency services without any prior approval. This is true even if the ER is out of network [1]. The plan also cannot make you pay a bigger share for an out-of-network ER than for an in-network one [1].

Was it an emergency? The rule asks what a "prudent layperson" would think. That is a person with average health knowledge. If such a person could expect serious harm to health, body functions, or organs without fast care, it counts. Severe pain is one such symptom [2]. The plan cannot decide this based only on diagnosis codes [1].

Your next step

If your ER claim was denied for lack of prior approval, file an appeal with the plan and quote 45 CFR 149.110(b)(1). Describe your symptoms when you went in, not just the final diagnosis. The sources here give no deadline; use the appeal deadline in your denial letter.

Check it yourself

Read your Explanation of Benefits for the denial reason. This rule covers group health plans and health insurers; it does not cover Original Medicare or Medicaid, which have their own rules — "Don't know yet" for those here.

Where this comes from (2)

[1] eCFR · 45 CFR 149.110 · § 149.110(a), (b)(1), (b)(3)(ii), (b)(4) · checked 2026-11-05
If a group health plan, or a health insurance issuer offering group or individual health insurance coverage, provides or covers any benefits with respect to services in an emergency department of a hospital … the plan or issuer must cover emergency services … ( 1 ) Without the need for any prior authorization determination, even if the services are provided on an out-of-network basis. … ( ii ) Without imposing cost-s…
[2] eCFR · 45 CFR 149.110 · § 149.110(c)(1) · checked 2026-11-05
Emergency medical condition means a medical condition, including a mental health condition or substance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (i…

How we found this

We matched your question to 2 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-05.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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